The
purpose of a GYN colposcopic examination is to evaluate the condition of a
patient who has cervical, vaginal, vulvar, urethral, or anal lesions be
combined either those of whatever additional tests may be necessary to reach a
complete diagnosis.
A
large variety of abbreviations and nomenclatures have been used to report
results. The recording media have included printed forms. Rubber stamps,
serial colpo-drawings, and even graphic picture systems.
A
uniform way of setting down all the normal and abnormal changes involving the
surfaces of the genital area usually makes of easier and more efficient record
keeping. Furthermore, this routine facilitates follow-up and improves
communication with the referring physician we have devised such an approach,
which we call a gynecoscopy record.
The
examination of Colposcopy
1.
The cervix is soaked with 3% acetic using packing forceps and saturated
cotton balls,
which are left in place for 60-90 seconds. A careful search
is made of the vanginal’ fornices’ and parts of the transformation zone
and cervix.
2. The cervix then is stained with quarter strength Lugol、s
iodine and all areas inspected again. After the application areas are
identified by their mustard yellow staining reaction.
3. If no source is found,
an endocervical curettage (ECC) should always be performed to exclude an
endocervical lesion.
4.
The lower vaginal walls should be inspected carefully as the Speculum
is withdrawn.
5.
If an explanation for the abnormal smear is not yet apparent,
the possibility of exfoliation from other sites must be considered,
e.g. endometrial,
ovarian,
fallopian tube,
or metastasis breast cancer. The possibility of cellular contamination form a
urinary lesion should also be considered.
After
making a colposcopic appraisal,
it is important to Draw an accurate diagran of the findings to summarize the
Appearance of the cervix just examined Biopsy sites should be recorded so that
past or future Histology reports can be related to colposcopic diagram.
The
radial position of the biopsy is recorded as 1 to 12 O、clock,
according to a clock face. The cephalic-caudal
Position
of the biopsy is recorded as A-E,where:
A.
Denotes a biopsies proximal to the new SCJ.
B. Denotes a biopsies immediately peripheral to new SCJ
C. Denotes a biopsies from a more distal portion of the transformation
zone
D.
Denotes a biopsies from the cervical portion distal to the original SCJ.
E.
Denotes a biopsies from the vaginal wall.
Diagnostic
conization is mandatory for an unexplained cytologyc report predicting
moderate dysplasia or worse in a woman with an unsatisfactory
Colposcopic
exam. However,when
with faced with an unexplained suspicious smear in younger women and in
patients in whom the transformation zone is fully visible,
the decision for cone biopsy should be individualized. The most common
explanation is a papillomavirus infection of the vagina,and
such lesions must excluded first.
The
overall predictive accuracy of the combined colposcopic index is higher than
95﹪.Furthermore,generating
a colposcopic score is simple.A diagram that defines the colposcopic
appearance is drawn,points
are scored for each of the individual criteria,
and then points are added to give the colposcopic index.
Warning
Signs to Safeguard against Overlooking Invasive Cance:
1.
Yellowish epithelium especially areas that bleed when touched..
2.
Colposopically significant areas (index score
³
6 points) with an irregular surface.
3.
Surface ulceration (particularly when bordered by acetowhite
epithelium).
4.
Atypical vessels (horizontal surface capillaries disptaying a
“tadpole” or “comma”shape;
5. coarse subepithelial vessles showing an irregular caliber and a long,
unbranched course).
6.
extremely coarse mosaicism or punctation,
especially if there are wide,
irregular intercapillary distances.
7.
Large complex lesions (dull,
“oyster-white”epithelium occupying 3 or 4 cervical
8. Quadrants and showing a mixture of high-grade colposcopic patterns).
9.
High-grade corposcopic lesions extending >5
mm into the cervical canal.
10. CIN 2 or 3 on a tangentially sectioned punch biopsy in which the
bas3ment membrane Cannot be defined adequately.
11. Cytologic evidence of possible squamous carcinoma (CIS cells in large
syncytial sheets,
12.
prominent nucleoti, bizarre cells,
or a “dirty background”)
13.
Cytologic
evidence of adenocarcinoma in situ.
14. Recurrent abnormal cytology in a patient previously treated for CIN 3
(e.g. by cryosurgery,
cone biopsy,
or hysterectomy).
15.
A Pap smear suggestive of CIN2 or higher in a postmenopausal woman.
Table : Scoring system for the
Colposcopic Index
|
|||
Margin
|
Exophytie
condylomas;
areas
showing a circular or micropapillary contour semicircular Lesions
with distinct edges. Feathered,
scalloped edges. Lesions
with an angular, jagged shape. “Satellite”
areas and acetowhitening distal to the original SCJ. |
Lesions
with a regular
(Circular
or semicircular) shape, showing smooth, straight edges. |
Rolled,peeling
edges
|
Color
|
Shiny,snow-white
color. Areas
of faint (semitransparent) whitening.
|
(Shiny,but
gray- white) |
|
Vessels |
Fine-caliber
vessale, poorly formed patterns.
|
No
surface vessals. |
|
Iodune
|
Any
lesion staining Mahogany
brown Mustard yellow staining by a minor lesion(by
frist 3 criteria)
|
Partial
iodine Staining(mottled pattern)
|
or
more points by the frist three criteria
|
1.
Scores of 0 to 2 are predictive of menor lesions (subclinical HPV infection
and CIN 1 ).
2.
Scores of 3 to 5 usually indicate a middle grade lesion (CIN 2).
3.
Sores of 6 to 8 generally denote an aneuploin epithelium (CIN 3).
An
European proposal for a colposcopic calssification
Colposcopic Conclusions |
Colposcopic Terms |
|
Normal
findings |
a.
Original squamous epithelium b.
Columnar epithelium(ectopy) c.
Normal transformation |
|
Abnormal
findings |
Non
suspicion zone |
Unusual
transformation grade
0 |
Doubtful
zones |
a.
Unusual transformation grade
1 b.
Fine mosaic c.
Fine punctation d.
Fine leukoplakia e.
Erosion |
|
Suspicious
zones |
a.
Unusual transformation gradeII b.
Coarse mosaic c.
Coarse punctation d.
Thick leukoplakia e.
Lrregular vascularisation f.
Ulcer |
|
Frank
invasive cancer Condylomatous
aspects Miscellaneous Inconclusive
findings |
|
Proposed
new colposcopic Terminologies
A.
Normal Colposcopic Findings Original
squamous eqithelium Columnar
eqithelium Transformation
zone B.
Abnormal Colposcopic Findings 1.
Within the transformation zone
Acetowhite eqithelium
Punctation
Mosaic
Leukoplakia
Condyloma Accuminata
Subclinical Papillomavirus Infection
Atypical vessels 2.
Outside the transformation zone (e.g.ectocervix.vagina.vulva
and penis) Acetowhite
epithelium Punctation Mosaic Leukoplakia Condyloma
Accuminata Subclinical
Papillomavirus Infection Atypical
vessels C.
Colposcopically suspect frank invasive carainoma D.
Unsatisfactory colposcopic findings E.
Miscellaneous findings |